Comprehensive New Client Intake Form | Cassandra Shuck Counseling

First Name *

Last Name *

Date of birth *

Email *

Phone *

Address *

City *

State *

Postal code *

Country

Emergency Contact *

Emergency Contact Phone *

Relationship

Spouse / Partner

Parent

Friend

Other

Are you currently receiving psychological services, professional counseling, psychiatric services, and/or any other mental health services?

Yes

Are you currently taking any psychiatric prescription medication?

Yes

If so, what medications are you taking?
Please list dosages and frequency.

Have you been psychiatrically hospitalized in the past? *

Yes

If yes, please list dates below:

Do you consume alcohol regularly? *

Yes

In one month, how many times do you have four or more drinks in a 24-hour period?

What kinds of recreational drugs do you use:

Are you currently in a romantic relationship? *

Yes

If yes, how long have you been in this relationship?

On a scale from 1-10 (10 being great), how would you rate the quality of your relationship?

In the last year, have you had any major life changes (e.g. new job, moving, illness, relationship change, etc.)?

Do you practice a religion? *

Yes

If yes, what is your faith?

Are you currently employed? *

Yes

If yes, who is your employer?

What is your position?

Are you happy in your current position?

Yes

Does your work make you stressed?

Yes

If yes, what are your work-related stressors?

The following is to provide information about your family history. Please mark each as yes or no.

Depression *

Yes